Page

1

Expanding paramedic scope of practice in the community

2

Page

Authors Blair L. Bigham, MSc ACPf Prehospital Science Investigator, Rescu, Li Ka Shing Knowledge Institute, Keenan Research Centre, St Michael’s Hospital, University of Toronto

Sioban M. Kennedy, MA ACP Education Coordinator, Sunnybrook-Osler Centre for Prehospital Care

Laurie J. Morrison, MD MSc FRCPC Robert and Dorothy Pitt Chair in Acute and Emergency Medicine Director, Rescu, Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michaels Hospital Professor, Division of Emergency Medicine, University of Toronto

Contact Blair L. Bigham Rescu, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital University of Toronto 30 Bond Street Toronto, Canada M5B 1W8 Web: www.rescu.net Email: [email protected]

Page

We would like to thank the members of the Ontario Paramedic Interest Group for their leadership and guidance in developing the search strategy and conducting the literature review: Ellen Bull, Rob Burgess, Jaclyn Day, Marlene Gray, Shannon Koppenhoefer, Glenn Munro, David Ralph, Dr. Brian Schwartz, Charles Shaw and Walter Tavares. We would like to acknowledge Carolyn Ziegler’s contribution to the comprehensive search through her role within librarian services at St. Michael’s Hospital.

3

Acknowledgments

4

Page

7

Background

8

Methodology

10

Summary of Evidence

11

Evidence-Based Recommendations

15

Conclusion

16

Bibiliography

18

Page

Executive Summary

5

Table of Contents

6

Page

Executive Summary

Method An international group of experts developed a search strategy and a health information specialist executed this search in 3 medical science indices for articles published in the last decade. We included all English research studies that reported a research methodology in our review. Two authors independently screened citations in a hierarchical manner. Differences were resolved by consensus. The data was abstracted and results were synthesized.

Summary of Evidence Over 2420 articles were screened and 9 met the inclusion criteria. The scope of the 9 studies was mixed, and 3 of the papers were derived from a single randomized controlled trial. This trial showed that community paramedicine may be beneficial to patients and health systems in terms of both clinical outcomes and cost effectiveness. Patient satisfaction was higher in the group treated by community paramedics. The other

Evidence-Based Recommendations Several recommendations can be made based on limited available evidence from a single randomized controlled trial of community paramedicine: A randomized controlled trial of community paramedicine in the Canadian health care system which addresses the shortcomings of the current literature is justified prior to widespread implementation. A needs assessment is required to understand the types of services that may constitute a community paramedic program as the intervention for the trial. Outcomes for community paramedicine studies should include clinical, operational, safety and patient satisfaction variables and may form the basis for developing quality and safety metrics post implementation. If community paramedicine is superior over the current standard of care, it may prompt curriculum change in college programs to ensure new graduates are well trained.

Conclusion Community paramedicine research to date is lacking, but one randomized controlled trial showed that paramedics may safely practice with an expanded scope, improving patient outcomes and satisfaction. Further research is required to fully understand how expanding paramedic roles affect health outcomes, the system of care and the cost of health care delivery.

7

Paramedics are an important health human resource and are uniquely mobile in most communities across Canada. Recently, challenges in the delivery of healthcare have prompted governments from around the globe to consider expanding the role paramedics play in health systems. Utilizing paramedics for the management of urgent, low-acuity illnesses and injuries has been coined “community paramedicine” but the role, safety and effectiveness of this concept is poorly understood. We undertook a review of the international literature to describe existing scientific evidence related to community paramedic programs.

studies drew conclusions favouring community paramedicine, however their methodologies were weak and their results must be interpreted cautiously.

Page

Background

Expanding Paramedic Scope of Practice Background

These observations have lead to a paradigm shift to increased use of allied health professionals to carry out assessments and treatments traditionally delivered by physicians1, 13-15.

In light of this diverse scope of practice, many have suggested that paramedics may be well suited for treating patients with minor conditions in the field or referring them to non-ED health resources. This may potentially reduce EMS and ED workload, increase system capacity, improve patient satisfaction and improve clinical outcomes but must be done safely. Many terms have been used to describe paramedics with an expanded scope of practice; emergency care practitioner24, extended skills paramedic25, community paramedic26 and paramedic practitioner27. The International Roundtable for Community Paramedicine28 (IRCP) is a network of EMS leaders pursuing the concept of expanding paramedic scope; given international participation in this organization, we have adopted the term “community paramedic” for the purposes of this report.

8

Most EMS models only allow providers to treat and transport patients to an Emergency Department (ED) for further treatment although as many as 50% of patients transported to ED by EMS are discharged without significant treatment or referral9. It has been estimated that 31% of all ED visits are inappropriate10 and that some patients transported to the ED by EMS leave without ever being seen by a hospital-based health care professional11. In rural settings, a lack of health infrastructure makes health care delivery difficult, and the presence of paramedics especially valuable3,12. In EMS systems with low call volumes, paramedics may be utilized more effectively to provide community based care as well as traditional emergency response. Further, this comprehensive community care may reduce the need for unnecessary transport of patients. This is important in a rural setting as transport time can be long and this takes a vehicle out of service for the next emergency call.

While variable by region, paramedic scope of practice may include delegated medical acts such as; endotracheal intubation, needle thoracostomy, intravenous access, medication administration of antiarrythmics, narcotics, dextrose and inotropes, and electrical therapies including defibrillation, cardioversion and transcutaneous pacing. In recent years, the scope of practice may have expanded to include fibrinolytics in ST-elevation myocardial infarction (STEMI)16 and hospital bypass for STEMI17 and suspected ischemic stroke18. Less critical conditions including hypoglycaemia19, epistaxis, and falls20 may be managed exclusively by paramedics and often result in no transport to an ED. Some have suggested that, given the unique opportunities paramedics encounter in the field each day, health promotion and injury prevention should also be added to the scope21-23.

Page

Health care demand is increasing around the world as populations grow and age1-3. Emergency Medical Services (EMS) have been impacted by the increasing need for their services with requests for emergency ambulances rising by as much as 8% annually4-6. Many of the patients for whom EMS is summoned do not require emergent interventions by prehospital care providers6, 7 and may best be served by other health services through referral by prehospital care providers8.

9

physicians, EMS operators, policy-makers and researchers who design, manage and measure EMS and healthcare systems.

Page

Our objective was to systematically review the international literature to identify scientific evidence related to community paramedics. This information is intended to inform

Methodology Data Sources and Search Strategy

Data Selection

We conducted a systematic review of the English literature to identify scientific evidence regarding community paramedicine. Our process followed the Cochrane methodology29. We searched Medline, Embase and CINAHL databases from January 1, 2000 to June 30, 2009 for all relevant articles. To find all relevant citations related to community paramedicine, we used a complex set of search strategies that combined medical subject headings and text words for terms related to emergency medical services, paramedics and community health. The search strategy was developed by the investigators in consultation with the Ontario Community Paramedicine Interest Groupa, the International Roundtable on Community Paramedicine (IRCP)b and an information specialist. We identified additional articles by hand-searching bibliographies of all included articles and contacting experts in the field.

We included all research studies that measured an outcome (health, cost, safety, risk) related to paramedic provision of expanded scope of practice. We excluded opinion articles, commentaries, and letters to the editor; however, we hand reviewed bibliographies to ensure we had not missed eligible studies. Two authors reviewed all citations independently in a hierarchical manner; title, abstract, full article. Titles classified as “include” or “indeterminate” by at least one of the investigators were included in the next level of review. Disagreements at the full article level were resolved by consensus between the two authors.

10

Two authors (BB, SK) independently abstracted the variables of interest using a data abstraction tool: the study design, the population demographics, the control and intervention, outcome data, the type of EMS provider and the EMS setting. Any abstraction differences were resolved by consensus.

Page

a: The Ontario Community Paramedicine Interest Group is comprised of representatives from municipal EMS services in Ontario that are exploring community paramedicine models. b: The International Roundtable on Community Paramedicine (IRCP) can be found at www.irpc.info and includes EMS researchers and administrators in its membership who share an interest in pursuing community paramedicine.

Data Extraction

Summary of Evidence

Where did the studies originate? Studies originated from North America, the United Kingdom and Australia. The studies from the United Kingdom were set in urban and suburban centres20,25,27,30-33, while both the Canadian34 and Australian35 studies primarily focused on rural and remote areas where health services access is limited due to a lack of health human resources. In Canada, Australia and the United Kingdom, the impetus for expanding paramedic practice originated with government white papers exploring alternative models of health care delivery1, 3, 36. What methods did the studies use? Only one study was a randomized controlled trial (RCT) which investigated the efficacy of community paramedicine in the UK, and the findings were supportive of community paramedicine27. The remaining body of evidence was limited to case-control, observational studies, economic and safety studies, and surveys20,25,30-35. To help advance research in this area the current evidence is summarized and we focus on the randomized controlled trial from the United Kingdom.

The scope of community paramedicine in the UK RCT was tailored to the needs of the community and all participating paramedics received enhanced training in assessing and managing minor or low acuity patients beyond the capability of a standard paramedic. This included the assessment of minor, acute illnesses and ailments, providing alternate pathways for further assessment, treatment and follow-up, and providing on-scene education in injury prevention and chronic illness surveillance27. Daytime care provided by community paramedics studied by Mason and others included alternate disposition pathways aside from the emergency department. These alternate pathways included protocol driven referrals to radiography clinics, general practitioners, district nurses, and social services.20, 27 These community paramedics had enhanced skills (Figure 1) that allowed them to treat patients at home for minor illnesses or injuries (Figure 2) and then leave the patient at home without recommending transport to ED. The decisions were guided by protocols and skill development which enabled the provider to suggest self care, referral to an agency or transportation to an ED.20

11

There were 9 papers relating to 7 studies that met including criteria20, 25, 27, 30-35. Most studies were excluded because they were not related to community paramedicine or were narrative descriptions of community paramedicine programs without data.

Page

How many articles were found?

What was the scope of practice of the community paramedics in the United Kingdom RCT?

minor allergic reaction, insect bite/sting boils and abscesses post-op wound/dressing problems minor wounds and lacerations minor soft tissue injuries and burns epistaxis foreign body (ear nose throat) sore throat, cold and flu toothache seizure in known epileptics resolved hypoglycemia in known IDDM back pain diarrhea, constipation blocked urinary catheter emotional or hysterical reaction alcohol intoxication social problems fainting falls

The role paramedics played varied across the other non randomized studies. In the UK, community paramedics also played a role in triaging calls to 999 (911) and were utilized in dispatch centres to enhance the capture rate of patients who would benefit from community paramedic care33.

Paramedics also provided injury prevention initiatives including falls prevention, first aid and safety training and car seat clinics.34

Reeve observed that paramedics with additional training could help to fill the niche of service currently under resourced due to a lack of physicians in rural and remote areas of Queensland, Australia35. Martin-Misener described a similar extended practice for the paramedics of Long and Briar Islands in Nova Scotia, Canada34. Services of this model include expanded patient assessments, ordering screening tests for bone density and some cancers, chronic illness identification and surveillance, medication compliance monitoring, and health education.

Community paramedics may have a positive effect on patients and the health care system, including a reduction in ED attendances and inpatient length of stay. The UK RCT by Mason (2007) found several potential benefits after conducting the randomized controlled trial of community paramedic care versus standard paramedic care: patients were less likely to attend the emergency department either at the initial episode or within the next 28 days (62% vs 88%, p